Loading...
HomeMy WebLinkAboutBuilding Permit #724-2017 - 487 WAVERLY ROAD 1/18/2017�►ulNl�-�l BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: Date Issued: LOCATION LA`J J U PROPERTY OWNER MAP PARCEL Date Received ,TANT: Applicant must complete all items on this page v erg kal - V tt L1D ,°TryNd ° J Pr'*t Print 100 Year Structure yes no ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Resi ntial Non- Residential ❑ New Building fftne family 0 Two or more family ❑ Industrial ,,Addition Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer DES, t11 1 6, xAft rAM1 PTION OF WORK TO BE PERFORMED: dL P V r%DSLQf IIt! `I/dentification - 1 LK -0 OWNER: Name: N -01 a`S Address: LA rJ-)' W av Cr�ti NIZ) Type or Print Clearly I) -,� - p q l P Contractor Name: V\JV % Phone: qQ) 3 Seo • 3 e 3 Email i r Address: ?n 19oN 749 1 / sw In rla Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: a ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BOLDING PERMIT.• $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ Oso -iy FEE: $ Check No.: l O Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund e Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS Reviewed On Signature_ Reviewed on Siqnature Reviewed on Siqnature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes x Planning Board Decision: Conservation Decision: Comments Comments Water & Sewer Connection/Siqnature & Date Driveway Permit DPW Town Engineer: Signature: LOcatea ;Jd4 USgooa Street FIRE D§P�\R,,TMENT. Tem Dumpster on site yes Y Located at1�24 Main Street +xts17 k COMMS±NTS' Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A —F and G min.$10o-$1000 fine NOTES and DATA — (For department use) ® Notified for pickup Call Email E' I Date Time Contact Name Doc.Building Pen-uit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits Building Permit Application Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses Copy of Contract 46 Floor Plan Or Proposed Interior Work Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks Building Permit Application i6 Certified Surveyed Plot Plan Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Mass check Energy Compliance Report (If Applicable) Engineering Affidavits for Engineered products TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) Building Permit Application Certified Proposed Plot Plan Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Building Permit Revised 2014 Locatio '1 L/V v c rZ t PC). No. `�'4�� } Date Check #IV o 451 TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee Other Permit Fee TOTAL Building Inspector Lu LL. O 0 OLLJ m u Y O O LL N Q N {n p Uu p• Z z c co 7 O LL � O d' cu ..0 U O LL cit O N Z C7 Z co .=.1 d 7 O !r f0 C LL O N = Z J V J LU O �' U N In 19 O LL w H Z Q l7 L j O 2' ID C LL Z LU Q LU cc LL i m Z ) v i N QJ Y O In JV �O L 49 _Q 2 z z W w IL W W 0- N N CD E w -4W z N W i d O V CL 0 V 0 U rmil cn ^ CD CD = a ca 0 �� m m. H � O O C CL �a :c r M J � o z� U) r— DocuSign Envelope ID: EDC15234-6E91-42E1-981&AB49D98A073A Permit Authorization alss gave Form Site ID; 50230371 Customer; 2 NICHOLAS RAND (owner's Name, printed) NICHOLAS RAND , owner of the property located at: 487 WAVERLEY RD NORTH ANDOVER (Property Street Address) (City) ,-4k iatrtwt PARTICIPATING CONTRACNII hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. Docu3igned by: McG,ef as rII l Owner's Signature: Date: 10123/2016120:46 EDT 4 FOR CLEAResult OFFICE USE ONLY CLEAResult has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: GW i -(' /Y\5 �,A mAi Ort , \ W'_ Participating Contractor Date CLEAReSult a 50 Washington Street, Suite 3000 a Westborough, MA 01581 a 1800-480-7472 Rev. 102015 OsrO F --r CfPice Use Ur- IV DocuSign Envelope ID: 3BDE885B-9C87-45E8-9Cl8-A97D65=A97 V - This service is brought to you through support from your local unlit This Agreement is made by and among an,d Nicholas Rand 4X'7 Fant R�J' GMAResidt 'N Atliu �HES Au ov;�r. X -Lk ell 84, -4218 50 Washirtgqon Street, Suite <3000 Site ff)�� S00050230371 Westbormigh, MA 01581 T'r-diccl -P-J: F,0005'0 , 21642 i4 Federat ID No. 222457170 Ou s to m -, r 'ff); C-0 salt 5 Q 21 f 1) (Mail eonipleted contract to addressabove) f,o 1'� tra t, .1 T� ID: >0 {tit;: W 0R K 1. DESCRIPTION OF WORK TO BE PERFORMED Conliuctor will perforin or (-auso to be Imiforined the folloNving work oil these "Prenii-A-.s"� M aprofe,,*0najjl �faillier and in accordance %%ith tile ternis or this Colih-act, including file attached recontinexidatioi&work order de-,-iihinq the work in detail (the "W'ork') wNdi are incorporatml livreja ll}� referejlcr_•: T "nocivoni 1, r Vent bath fan tc, I'l ins;!1a.te Viicod S,��onnO- S-1d'edVVL;,i `041,�, 4� P -6-n,, C-'eti-1k,5e mst,,Iata Ri-.i-, Jais" %vith 6, 255 — 0 f, 5" F I 'r of-Sice uae or -.y L_;cafion Uv,J',r,Q Spare 'o 49-21'i S j Sub ;?;,k S-, 5. „� Fi Co.-Aribution IL PAYMENT CusLoineragrevs to jxky c ontrac-tor for the Work, file Customer Shar(a fir tile Contrad Price as follolvs: Payment, 41: ;is a Deposit, payable to CLEARes4mit upon signing the rthe frit .4rel" ail MSts)- Mail check & contract W CLEAResult, Ste. 30M, Westborough, IMA 01581-rinal Attn: IIES, .50 Vftshington St., as the filial t)ziynient for the Wofl, silvd). be. payable to the independent Installation Contractor (1111C") upon satisfactory completion Of the lVork. Customer widerstands that hoishe Still flot be rt-quired to pay the L'I ity 111cellfive 'L , �, Sh,we of the Coniniel plic(.. ill of,�. 1 il hicentive Sharp. CXX !­ Cllangoq u) individtial lifle hems alid"or previous; hicelifives Mky illermse or dlefTease the size orille Onlity III. DISPUTE RESOLUTION lliellCanti illutwilly agree in advance dial in the event. thai ract;the HC my subluil Service -Miicli has been q)prm.ed by the Offiv,(, of ColL. ruler Aft nits .incl liusine s Ht n�azlation aunt C'rt�totrier .4 a if) SMIAllit to --Aldl albitrafioll as pivildiled in You may cancel this agreement if it has been signed by a party at a place other than an address of the seller, provided you notify the seller in writing by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third b L fiud f*llowing the signing of this agreement. DO NOT SIGN THIS CONTRACT IF THERE ARE 99 BLANK SPACES. 12/27/2016 1 09:17 EST B4 hidicate yo Secc, er I t I 11C here, if apFh7,7a­bJ, (OR)Initial here u.jroll wan, the Prograw to a -sign a CLEARe.411 Date Name of CLEARe-sult Repre� d) Part-icimiting Contractor TERMS AND CONDITIONri "PEAR ON ME HLEVMSE.. 2211 J2-111.16 DocuSign Envelope ID: EDC15234-6E91-42E1-981&AB49D98A073A 117 11'- " '111111. ? s Agreement is made by and among Nleftelav ItAncl 47 Waverley Rd North A nJover, 3MA 01945-218 Site M S0405423037l, Rruiect JD:.%1 0050264214 Customer 1D.- C000502319a5 Contract ID- 20160825 ASEAL NINUM W1,7111 ThK sarvi{p is brough t{l yoll ttirougfi support ff011) your local utilit and C;LEAResult Ann. IfES 50 Washington street., f-;laite 3()()() Wes€borougin., iyIA 01581 r, ederai. ID No. 22-M,5 t 173 (N -W) completed contract to adclrcess above) f. DESCRIPTION OF WORK TO BE PERFORMED Contractor will perrorna t,n c .rase to 1w perfornied lice ful}owhtg tkork on these "F)tentt.ses: in a professional manner and hi accord mice. xvith the ):earns o: this Contract., including the <ulaehetc} re'c:ontntentlatiottslH'or'lc order (lcseia)i tg the work in detail Ithe 'Work-) ividein atC int:iatpctatetl herein by reference: Description Perform Air Seating at EsUmated 62.5 CFW150 Per Hour Boar Sweep Exterior moor Weather Stripping 110 ".© For office use only Quantity Location 6 Living Space $505.92 3 N/A $69-54 3 MA $82.77 Sob Total: $658.23 utifty lxtm—hive Share $658.23 Customer Contribution $0.04 Printed- i(j120/20j6 Page 2 of 2 If. PAYMENT •r. {_:U.4IA)1110r an_e e�tca p,ay Cunixactor for the Work, the Customer Shue, of the Contra to CLE 4liecailt. upon sinning the ct Pace asfotioet Pavntenl ;t}: S `" �. _ <rs a L)cl C"sosit payable ont�ract (tioi t o extee-1 V3 uF Jtr. rma) rr-tstjl z c, ts). t t€sd clteei� c contxct; ato C;LEtkiesuli, tAtta RFS, 50 Washington St., Ste. 3000, Westborough, i6l k Oiar31, 1 inatl ta:trmt aat _ _ as tlu-. r a al payment tcrtitt' !Pori. shall ht, payable to the Independent Installation Contractor ("TIC-) upon satisfactory completion of—iorh. C,ustomcgr nndetstands that. helsh, at•lll arcs{ i)e required icr lztt° the tltilitZ htct�ntite Sh<ta e of Ute (aCZ isticc in the artu>unl: of $ . ,t��f' +: . (;hangcs to inriiciduai line items anchor tnvvinus incentia c , tn.lz� inc•t�+ease or decrease: the .size of t;}te Utility ince ntivc Share. Ill. DISPUTE RESOLUTION The ITT ai-1d t:ao.omer he rl, Isv m[at"Wtv,aptl in advance *juu in t<rc> c%(•nt that. fl,* TIC: has za,-6-prate x oaweayeirg dtisicnc�4, tlae liC eta; snlza)tit: ti�tt:i3 cl�raiTc: ifs; i sc n ice wfiatlr h.0 I""' y);n otizxi by the ()Hx t of {'otastuncr Aff itas aaacl llcGsin ss 12`Pi4tti�n and Ctsstomr r ylaeill be regiii�l to submit to such art)itaxiion as Pro dVil in`ti4X;J1 (#11 ),A You May cancel this agreement if it has been signed by a party at a place other than an address of the seller, provided you notify the seller in writing by ordinary mail pasted, by telegrarn sent or by delivery, not later th midnight of the third buss el�ltJa'lEBg the signing a# this agreement. tea NOT SIGN Tl-il5 CONTRACT IF THERE A fY BLANK SPACES. S t a 1012312016120:46 EDT Gaston < 5, ttc indic:atc your soccrvo fie hea c . if appl}cahir, y)J`j irtii} fl }IPrP if nota want K:�.�...... 1J the 7fio J11 to aw s} 1 a Gl l:r1l?esull 5z tat- re s hate N1'am al {.1,i :1)Zestd1. 64)re4ii 1-Aa1e (Print, d) Participating Contractor 'lltE11EMS AND CtiBNIlB>;f`f ONS APPEAR ON T", 7RE. wERS E, The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 '' www.mass,govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ARRH= I n Please Print L 1 Name (Business/Organization/Individual): G w W% tr insO kNr \ 1 VA, — Address: If - C) Bax `34q i Lt\ h A 01°13 5 Phone #: Are Lou an employer? Check the appropriate box: 1.I am a employer with 4. ®I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ® I an a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance required.] comp. insurance $ 5. ® We are a corporation and its 3. ® I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, §1(4), and we have no employees. [No workers' comp. insurance reauired.l ,3411 Type of project (required): 6. New construction 7. ('� Remodeling 8. ® Demolition 9. [j Building addition 10.® Electrical repairs or additions 1 l.® Plumbing repairs or additions 12. ® Roof repairs 13. ® Other *Any applicantthat checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. Tam an employer Mat lsproviding workers' compensation insurance for my employee& Below is the policy acrd job site iq ormadon. Insurance Company Name: he -OL Policy # or Self -ins. Lic. #: Expiration Date: 10134 0 tt ( r Q 1 eK. ' Job Site Address: v,, l l!J v City/State/Zip: J ih �& V C r ` 0 Attach a copy of the workers' compen stion policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the forth of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby centfy under the pains and penalties of perjury that the information provided above is true and correct. PhQneM 6, -_t - *1 S ko - l'i esI O&kd use only. Do not write in this area, to be completed by city or town gffickd. City or Town: Permit/iicense # 110 Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector 6. Other Contact Person: Phone #: AC10CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDA'YY1f7 F 1 011 8/201 6 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In Ileu of such endorsement(s). PRODUCER MARTIN J. CLAYTON INSURANCE AGENCY INC ryANjg T meg Munroe PHONE 536-0804 ac No): ffihI413) ADDRESS: mmunroe m'cla on.com COMMERCIAL GENERAL LIABILITY INSURERS AFFORDING COVERAGE NAIC�i 1649 NORTHAMPTON ST., RTE 5 INSURERA: ACADIA INS CO 31325 HOLYOKE MA 01041 INSURED INSURER B: INSURER C: GAUTHIER INSULATION INC INSURER 0 : INSURER E: PO BOX 344 1 INSURER F: IPSWICH MA 01938 r_AVFRAnFA P-FRTWIP.ATF NIIMRFR- QAr%91 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF M°��YYr LIMITS NORTH ANDOVER MA 01845 COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE F� OCCUR DAMAGE TO RENT90— PREMISES Ea occurrence $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ N/A GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ POLICY ❑ PRCFIJECT [7 LOC $ OTHER: i AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ ANY AUTO BODILY INJURY (Per accident) $ ALL OWNEDSCHEDULED AUTOS AUTOS HIRED AAUUTOSTOS ED UTOS N N/A PROPERTY DAMAGE $ Per accident UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE N/A DED RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANYPROPRIETORIPARTNER/EXECUTIVE - OFFICERIMEM BER EXCLUDED? WAWA (Mandatory In NH) WA MAA 10/30/2016 10/30/2017 X I STATUTE I ER" E. L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE - POLICY LIMIT Is 500,000 If yes, describe under DESCRIPTION OF OPERATIONS below N/A DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued (unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage - Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. CPRTIFIrATF HAI nFR CANCELLATION ®1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26 (2014101) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF NORTH ANDOVER ACCORDANCE WITH THE POLICY PROVISIONS. 1200 OSGOOD STREET AUTHORIZED REPRESENTATIVE NORTH ANDOVER MA 01845 Daniel M. Crowley, CPCU, Vice President — Residual Market — WCRIBMA ®1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26 (2014101) The ACORD name and logo are registered marks of ACORD DATE (NNWWT r 11 WORD CERTIFICATE 4F LIABILITY INSURANCE 1 7/14/2016 ERS NO TE HOLDER. THIS THIS G RTIFICATE IS ISSUED AS A MA'REQOF INFORMATION ONLY AND CONF R NEGATIVELY AMEND, EXTEND OR ALTER RIGHTS COVERAGE AFFORDED ABY THE POLICIES CERTIFICATE DOES NOT AFFIRMATIVELY BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZE REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder 18 8111 ADDI'110lic0NAma� SegWreURED� y n endorsement. A statement (jes) must be on R this certlficate daps not canteErDraghts to the the farms and conditions at the policy, Pa aeftlfl— holder in Ileu of such endorsements . Nancy Usher PRODUCER SME' FAX .(413)534-7874 PHONE (413)536-0804 Martin i Clayton Insurance Agencyr Inc. E•MAiL 1649 Northampton Street ADDRESS: NAICB INSURERS AFFORDING COVERAGE P. 0. Boa 989 Holyoke MA 01041-0989 INSURERA:Nat].Onwide Mutual -Earle sville NATIO-- INSURERS Allied World Nati Assurance Co INSURED INSURERC: (Gauthier insulation INSURER D: P .0 . BOX 344 INSURER E MA IPSWICH 01938 _....r...w •Tc u//aAQGQ•CL1663001B50 -.-_ _ __---„_ _,.,,r; on„ry DGRIf1 AVERAGES ver/ r 1 �...,. .._...-- - - THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HCH THIS AVE BEEN ISSUED TO THE INDICATED. NOTWITHSTANDING ANY REQUIREMENT,PERTAIN, THE NBUOR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN S SUBJECTPTO ALL THE TERMS, CERTIFICATE MAY BE ISSUED OR MAY P EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED OUCYFR PPOLICY EXP LIMITS ISR TYPE OF INSUVFD7 POLICY NUM 1,000,000 EACH OCCURRENCE $ X COMMERCIAL GENERPAEMI' a o e oa $ 50,000 CLAIMS -MADE i 5,000 A 7F 7/b/2016 716/Z017 MED EXP (A ale rson) $ PERSONAL & ADV INJURY $ 1, 000, 000 GENERAL AGGREGATE $ a,00o,000 GEN'L AGGREGATE LIMIT PRODUCTS - COMP/OP AGG $ 2,000,000 A POLICY ❑ JER& $ S G $ AUTOMOBILE UAMLVV ANY AUTO ASV ryEO SCHEDULED NON OWNED HIRED AUTOS AUTOS X UMBRELLA UAB OCCUR B EXCESS LIAR CLAIMS -MADE DED RETENTION WORKERSCOMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETORIPARTNER/EXECUTiVE (11N/A 89020792125-194985 110/18/201510/18/2016 BODILY INJURY (Per person) S BODILY INJURY (Per acddent) $ PROPE TY DR�AMAGE $ sacci ent $ DESCRUMON OF OPERATIONS I LOCATIONS / VEHICLES (ACOAD 101, Additional Remarks Schedule, may be attached N more space is required) CLEARESUI./r r RSOURCg AtiD NATIONAL ARIA ATItB LISTED AS ADDITIONAL INSUREDS ON A PRIMARY NON-CONTRIBUTORY BASIS CLEARESULT ATTN-. CONTRACTOR SERVICES DEPT 50 WASHINGTON STREET WESTBOROUGH, MA 01581 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE ACCORDANCE WILL BE DELIVERED IN E WITH THE POLICY PROVISIONS. AUTHORISED REPRESENTATIVE ,Daniel Sullivan/MEG �- _ to 1988-Am14 AC.ORD ACORD 25 (2014101) TW ACORD name and logo are regigWried marks of ACORD OMPIN ted with pdfFactorY trial version .Ddffacto.CoM al >j” rieservled FOD � S a 4.�ccr`?r kxslfPtt4A9 �, M W._-crO � P�< Z 66o0 1 i—V3: tL GC � N YY�a" ° » ` £■« . $ � \$ J2w $$, � J fs /2 @ ©J 7#§. ®� � / { \ #� & ° » ` £■« . $ � \2}( J fs @ ©J 4 29D �